87-363 - Laserfiche WebLink

Home Browse Search

-: -_ � w� APPLICATION FOR PERMIT + SAN JOAQUIN LOCAL HEALTH DISTRICT 1601 E. HAZELT ON AVE.,, STOCKTON, CA 4 Telephone (209) 466-17$1 y PERMIT EXPIRES 7 YEAR FROM DATE ISSUED (Complete in Triplicate) This aPPlr�nOn is Application is hereby made to the San Joaquin Local Health District for a permit to construct and/or install the work herein described• made in compliance with San Joaquin County Ordinance No.549 for sewage or No. 1862 for well/pump and the Rules and Regulations of the San Joaquin h Local Health District.,,-,. 3 / O 74 ,L S City S a C obi Lot s;:e o PM Job Address / C /may 1 �° 7 _ `s Name h/4r� /tf IMF,' r �'4 Address / ` ! �(�' 7 ! Phone 2 2 Z Owner �j Si h n Contractor Address License No. TYPE OF WELL/PUMP..: - NEW WELL ❑ WELf_REPLACEMENT �]. DESTRUCTION ❑ SYSTEM REPAIR ❑ PUMP INSTALLATION ❑ OTHER IJ }. SEWER LINES � DISPOSAL FLD. PROP. LINE DISTANCE TO NEAREST: SEPTIC TANK �--- AGRICULTURE WELL OTHER ELL PITS/SUMPS FOUNDATION { j INTENDED USE TYPE OF WELL PROBLEM AREA CONSTRUCTION P 1FICATIONS Dia of Well Casing ❑ 0 ttom ❑ Manteca Dia. of el xcavation ❑ Industrial Specifications Tracy of Casing estic/Private ❑ Gravel Pack Type of Grout Dom Yp ❑ I ea ❑ Other ❑ Delta Depth of Grout S e � ❑ Public Su eal Installed by L1 Irrigation �pprox. Depth ED] East n H.P. State Work Done ` Repair Work Done 11 Type of Pump50'1 Well Destruction El Well Material [tap Well Diameter Filler Material al (op 50'} Depth t TYPE OF SEPTIC WORK: NEW INSTALLATION ❑ REPAIR/ADDITION ❑ DESTRUCTION INo No system tem emitted it public sewer is k eet Installation will serve: Residence Commercial— Other -- k' Number of living units: Number of bedrooms Water table depth [ Cf ora of soil to a depth of 3 feet: No. Compartmentsr F Type/Mfg Capacity SEPTIC TANK - Method of Disposal PKG.'TREATMENT PLT. ❑ F ation "'Property Line Distance earest: Well 1 Total length/size j LEACHING LINE ❑ No. & Length of lines undation Property Line FILTER BED ❑ Distance to nearest: Well ` ❑ Depth Size umber SEEPAGE PITS Foundation Property Line I SUMPS ❑ Distance to nearest: Well DISPOSAL PONDS ❑ I hereby certify that I have prepared this application and that the work will be done in accordance with San Joaquin county ordinances, state.laws. an rules and regulations of the San Joaquin Local Health District. work for s permit is iss I l not Home owner or tone in such manner to becomfies the e subjectlowing: "I certify to workman's compensatiin on laws of Californiae performance of ," Contractor sohiring I orr sub-cont act nglsignlature f employ y Pe rsons subject to workman's compensa- tion the following:"I certify that in the performance of the work for which this permit is issued,I shall employ pe I tion laws of California." ` The applicant must call for all required inspections. Complete drawing on reverse side. Title: i Date: signed F R DEPARTMENT USE ONLY _.� Area Date Application Accepted yDate Date Final Inspe-�ctt��on ba,_r--CrD%n"– �e Pit or Grout Inspecti 3 �,� Additional Comments: `"` " © Manteca 823-7104. ❑Tracy �E� '(CJ ;'•s�C 1„ ❑ Stk 466-6781 ❑ Lodi 369-3621 Applicant- Return all copies to: C Environmental Health PermitlServices 1601 E. Hazelton Ave., P.O. Bax 2008, Stk.,�A�9 CK RECEIVED BY DATE PERMIT''NO. FEE AMOUNT DUE AMOUNT REMITTED CASH / INFO 041 _)1 ' + EH 13-24(REV. EH 14413 P.